Synopsis The tug Jose Narvaez was outbound from Vancouver harbour, at night, towing the coal-laden barge Texada B.C. on a 274 m cable towline. The operator of the pleasure craft Sunboy did not realize that they were approaching a tug/tow combination and passed between the tug and the barge. The propellers of the Sunboy became fouled in the towline, and the pleasure craft was struck by the on-coming barge, and capsized. As a result, some people were thrown into the water and others were trapped within the vessel's enclosed spaces. Of the 14 people who had been on board the Sunboy, nine were rescued and survived, four drowned and one remains missing and is presumed drowned. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessels Sunboy The Sunboy is a Bayliner pleasure craft (1998 model 4087), constructed of glass-reinforced plastic. It has three decks. The lowest of these consists of sleeping accommodation forward of an engine compartment; above it is a weather deck superstructure fitted with a control station on the starboard side of the salon. Atop the superstructure is an exterior command bridge deck with built-in seating and a second control station. Manufacturer's information states that the vessel has a cruising speed of approximately 15 knots. Jose Narvaez The Jose Narvaez is a single screw, steel-hulled tug. The weather deck is fitted with an enclosed deck-house forward of a main working deck. Atop the deckhouse is the boat deck with an enclosed wheelhouse with centreline helm, and windows providing an unrestricted view ahead but a restricted view astern. At the exterior, after end of the boat deck is a second set of clutch controls, an emergency towing winch release and a 150,000 candela searchlight. The vessel's service speed is approximately 7.5 knots. The vessel is equipped with 790 m of 45 mm diameter steel wire towline on a single drum towing winch. The winch has one local and two remote emergency release stations. Texada B.C. The Texada B.C. is a flush-decked steel barge used for hauling aggregate and coal products between West Coast ports in Canada and the United States. The hull is painted black and the 3 m high box walls are painted grey. There is reflective tape approximately 1 m long and 0.25 m to 0.30 m wide on the top of the box walls facing forward on both the port and starboard sides. At the time of the occurrence the barge was loaded with 5,200 tonnes of coal. The barge is connected to the main towline by a towing bridle consisting of two 20 m lengths of 32 mm diameter steel wire rope. The bridle is led forward from the port and starboard bollards of the barge and is shackled to the towline. 1.2 History of the Voyage 1.2.1 Sunboy The Sunboy, which is licensed in the United States, arrived in Canadian waters on the evening of 3 August 1999. The operator found a temporary berth at the waterfront premises of the Bayshore Hotel in the Coal Harbour area of Vancouver's inner harbour. On board were the owner/operator, his wife and their two children. On the following day, the family used the vessel to attend a nighttime fireworks display south of the Lions Gate Bridge, in a part of Vancouver's outer harbour known as English Bay. The fireworks are ignited from a barge anchored in English Bay near Vancouver's English Bay Beach. Two days later, on August 6, the operator found a new berth for the Sunboy at Thunderbird Marina, located in Fisherman's Cove in the nearby municipality of West Vancouver. During the late afternoon and early evening of August 7, the operator, his wife and two children along with 10 invited guests (three men, three women, one adolescent and three children) boarded the pleasure craft in preparation for an excursion to Burrard Inlet to view another fireworks display, scheduled to begin at 2215 Pacific daylight time, [2] one and a half hours after sunset. At approximately 2100 the vessel departed from her berth at Thunderbird Marina with 14 people on board and made her way towards the fireworks barge anchored in English Bay, approximately 4.5 nautical miles (nm) southeast of the cautionary light buoy QB. This buoy marks the terminus of the outbound lane of the vessel traffic separation scheme in Vancouver's outer harbour (see Appendix A). Prior to the accident, the Sunboy was proceeding at a speed estimated to have been between 14 and 15 knots, on a course later calculated to have been approximately 116(T). During the voyage, the operator had control of the vessel from the command bridge station, where he was joined by three children, one adolescent and three adults. In the salon of the main deck superstructure were four adults and one child. Another child was resting in the sleeping area forward of the salon. Two children were wearing lifejackets; the rest of the people were not. At approximately 2135, four persons were aboard a 5.3 m open pleasure craft (speedboat) making its way toward English Bay to starboard of the Sunboy. After rounding Point Atkinson it reached a position north of Vancouver harbour's outbound traffic lane. Seconds prior to the collision, the speedboat's operator became aware that the Sunboy was in danger of crossing between an outbound tug and its tow. In an effort to warn the Sunboy of impending danger, he shone a flashlight's beam in the direction of the Sunboy and then turned it on and off rapidly. Receiving no response, the speedboat operator reduced the vessel's speed, altered course to port and passed astern of the Sunboy to avoid the danger. At about 2142, having not recognized the tug/barge combination, the operator of the Sunboy steered his vessel between the tug Jose Narvaez and the barge Texada B.C. being towed 274 m astern. The pleasure craft came to a stop when, in rapid succession, her propellers and rudders fouled first the towline and then the starboard component of the barge's towing bridle. Unable to break free, the pleasure craft was forced onto a heading almost reciprocal to that of the on-coming barge. Within moments, the upper portion of the barge's port forward rake collided with the port side of the pleasure craft's command bridge. The Sunboy heeled quickly to starboard and capsized (at position 4918'53 N, 12313'57 W). As a result of the capsizing, some people were thrown into the water and others were trapped within the vessel's enclosed spaces. Survivors were rescued and taken by ambulance to a nearby hospital where they were treated and released. 1.2.2 Jose Narvaez/Texada B.C. At 1800 on August 7, the master of the tug Jose Narvaez assumed conduct of the tug, which was engaged in towing the loaded gravel barge Empire 40 toward the False Creek area of Vancouver harbour. During this transit, the unit was escorted by another tug through dense pleasure craft in English Bay. At about 1955 the Empire 40 was handed off to a local assist-tug and the Jose Narvaez proceeded out of False Creek, toward Vancouver's inner harbour via a five-cable-long, two-cable-wide waterway known as First Narrows, over which spans the Lions Gate Bridge. About an hour later, she approached a navy mooring buoy adjacent to the north shore of Vancouver's inner harbour, where the coal-laden barge Texada B.C. was secured pending the tug's arrival. In accordance with scheduling arrangements made via cellular telephone between the tug's dispatch office and the master, the tug was manoeuvred into position and her crew secured the barge to the tug by means of a steel wire rope bridle and towline. At 2100 the tug's master reported to Vancouver Marine Communications and Traffic Services (MCTS) via very high frequency (VHF) radio Channel 12 that the tug and barge were departing the navy buoy bound for a cement production plant in the Fraser River. At 2120, as the tug and tow were transiting westward through First Narrows into Burrard Inlet, MCTS advised the tug's master of the large number of pleasure craft and charter vessels gathering in the area in anticipation of the fireworks display. Consistent with normal practice, when the unit was one mile west of First Narrows, the towing cable was lengthened from approximately 60 m to 274 m and the tug's speed increased to approximately 7.4 knots. The on-watch deckhand left the wheelhouse after having been there with the master since their departure from the navy buoy. At about 2135 the Jose Narvaez was abeam of navigation buoy QB. Sometime later a spotlight was shone on an unidentified vessel believed to be a pleasure craft. By about 2137, the tug and tow were established on a course of 245(T), toward buoy QA to create more sea room between the tug and tow and small vessel traffic in the vicinity of Point Atkinson. In so doing, the tug and tow eventually entered the separation zone between the inbound and outbound traffic lanes. Steering was by automatic pilot and her engines were on wheelhouse control. The master decided to summon the deckhand to the wheelhouse using the intercom. As the intercom was not working, he descended a set of interior stairs in order to find him. After a brief search, the master found the deckhand in the galley and asked him to report to the wheelhouse. The master then left the galley and entered his stateroom to retrieve a cellular telephone, which lay ringing on his desk. Finding that the caller had terminated the call, the master then followed the deckhand up to the wheelhouse. Upon his arrival in the wheelhouse, the deckhand glanced out the starboard windows and then walked directly to the port side of the area. As soon as he had done so, both he and the master (who had also entered the wheelhouse) felt a jerk on the towline. The master quickly took all way off the vessel and proceeded directly to the control station located on the after, exterior boat deck; the time was about 2143. When he shone a searchlight upon the port side of the barge Texada B.C., he saw a grey object laying alongside the barge. The object was later identified as the upturned hull of the Sunboy. The speed boat operator, who had seen the occurrence, proceeded to assist and pick up survivors. The Jose Narvaez also stood by the area to assist until released by the Canadian Coast Guard (CCG) on-scene commander at 2251. The Jose Narvaez resumed towing the barge toward its Fraser River destination, arriving there at 0505, August 8. 1.2.3 Events Following the Occurrence At 2145 the Jose Narvaez reported to MCTS via VHF Channel 12 that the Texada B.C. was involved in a collision with a pleasure craft. Two minutes later, at 2147, MCTS initiated a Mayday call on behalf of the Jose Narvaez via Channel 16, which was answered by CCGC Osprey and CCG hovercraft HC-O45. By 2156 the Osprey was on-scene and by 2210 she had retrieved people from the water. Survivors picked up by the speedboat were also transferred to the Osprey, which, at 2217, arrived at a Department of Fisheries and Oceans research facility in the city of West Vancouver, which borders Vancouver harbour to the northwest. One minute later, at 2218, the first Emergency Health Services (EHS) ambulance arrived at the Fisheries dock and its attendants began first aid. At 2222 CCG divers entered the water and began a search of the capsized hull. At 2330 the first ambulance left for Lions Gate Hospital, in the adjacent city of North Vancouver. Subsequently, two more ambulances left for the same hospital. By 0500 on the morning of August 8, the wreck of the Sunboy had been towed in a capsized condition to the Fisheries dock, and later righted. The search for the missing person continued until 0143, August 8, at which time the Royal Canadian Mounted Police officially assumed responsibility for the search, which continued for a further 48 hours, but was unsuccessful. 1.3 Injuries to Persons Sunboy Survivors were rescued and taken by ambulance to a nearby hospital where they were treated and released. Nine persons survived, including the operator. Four persons drowned, including a five-year-old child, two women and one man. One man remains missing and is presumed drowned. The bodies of the man and child were located within the confines of the capsized hull and those of the women were found in the water, free of the vessel. Jose Narvaez/Texada B.C. 1.4 Damage to Vessels and Environment Sunboy The pleasure craft was extensively damaged, particularly on her port side. The significant structural damage was identified as follows: Photo 4 Damaged hull of the Sunboy port propeller blades were bent and fractured starboard propeller blades were bent, fractured or missing port rudder was bent back and upward sufficient to puncture the hull port portion of the underwater hull, keel and chine were heavily scarred port lifeline stanchions were torn away from their main deck fittings entire bridge superstructure was dislodged and broken in many places port salon window was dislodged and missing forward window directly ahead of the interior helm was missing. The small amount of diesel fuel released from the capsized vessel quickly dissipated. Jose Narvaez Texada B.C. The barge had three minor abrasions on the port side of the forward rake 1 m below the main deck. Abrasion marks were found approximately 4 m from the towing eyes on the port bridle of the Texada B.C. The abrasions were consistent over an area of approximately 4.5 m. 1.5 Certification of Vessels Sunboy The Sunboy carried a Washington State Vessel Registration Number reserved for recreational vessels. United States regulations do not require that pleasure craft such as the Sunboy be inspected. Jose Narvaez The Jose Narvaez is an inspected vessel and her current Transport Canada, Marine Safety (TCMS), Safety Inspection Certificate (SIC 22), to operate as a non-passenger vessel on Home Trade Class II and III voyages, was valid at the time of the occurrence. Texada B.C. The Texada B.C. was unmanned and carried no petroleum products or pollutants. Consequently, she was not inspected by TCMS, nor was she required to have been. 1.6 Vessel Crewing and Personnel Certification and History Sunboy The operator of the Sunboy did not hold a marine certificate of competency at the time of the occurrence, nor was he required to under United States federal or Washington state legislation. He had not attended formal navigation courses and had little boating experience, either before the purchase of this, his first vessel, in July 1997, or during the subsequent two years, when the vessel's engines had operated for 300 hours. Jose Narvaez The tug was routinely manned by two 5-person crews. At the time of the accident, the on-board crew was beginning a second consecutive week of work. Each deck watch was six hours in length and was kept by two persons: an officer of the watch who was either the master or mate, and one of two cook/deckhands. An engineer was in charge of machinery but was not part of the watch crew. Two 5-person crews normally rotated their duties aboard the vessel every Sunday. At the time of the accident, the on-board crew was completing the final day of its regular shift and was to begin a second week of work, after having made arrangements to do so with members of the alternate crew and the vessel's owners. The master of the Jose Narvaez held a valid Certificate of Competency. He had earned his livelihood in the B.C. towboat industry since 1953. After working 15 years for various B.C. tugboat companies, he satisfactorily completed Transport Canada (TC) examinations, and was issued a Master Home Trade 350 Ton Certificate of Competency in 1968. The Certificate was renewed in 1997 and was valid at the time of the collision. He had been employed by the owner of the Jose Narvaez since 1981, and since 1996 had held the position of Posted Master (Designated Master) aboard the tug. The engineer and mate both held valid certificates. The on-watch deckhand had no certification, nor was he required to have any. 1.7 Weather and Tidal Current 1.7.1 Weather Forecast The collision occurred in darkness, about one hour after sunset, which was at 2044 on August 7. The marine forecast for Vancouver harbour, issued by the Weather Centre of Environment Canada at 1600 on that date, predicted winds from the southeast at 10 to 20 knots with mainly cloudy skies and scattered showers or isolated thundershowers. On-scene weather was reported as being choppy seas, overcast skies, light southeast winds and good visibility. 1.7.2 Tidal Current The Canadian Hydrographic Service Tide and Current Tables, Volume 5, indicate that, on the evening of August 7, low water at Vancouver harbour was predicted for 2120, with a height of 3.3 m above chart datum, and the current at First Narrows was predicted to turn to flood at 2155. At the time of the occurrence, 2143, the tide was ebbing and the current was estimated to have been setting in a westerly direction at a rate of less than one knot. 1.8 Operating Environment 1.8.1 Geographical Information Vancouver harbour comprises two geographical entities: a relatively narrow industrial area east of First Narrows known as the inner harbour, with a rarely used eastern extremity known as Indian Arm. West of First Narrows is a wider area extending west to an imaginary line between Point Grey and Point Atkinson. This area, known as the outer harbour, consists of Burrard Inlet, English Bay and False Creek (see Appendix A). The fireworks display on August 7 was one of four held annually in the outer harbour. There are two displays each week for two consecutive weeks, beginning in the last week of July or the first week of August. Each event begins at 2215 and lasts 30minutes. The four events are known collectively as the Symphony of Fire. Each display is ignited from a barge anchored at position 4917'35 N, 12310'00 W, directly off English Bay Beach. 1.8.2 Traffic Before each fireworks event, including that of August 7, hundreds of pleasure craft depart numerous mooring sites in greater Vancouver and make their way through Burrard Inlet toward English Bay. Typically these vessels transit the inlet over a period of between two and four hours leading up to the beginning of the event at 2215. When the fireworks end at 2245, these same vessels return to their moorings over a much shorter period of between one half and two hours. Often, this leads to congestion around First Narrows, where numerous close-quarters situations occur both between pleasure craft and between pleasure craft and commercial vessels. Vancouver's traffic separation scheme begins approximately 2.5 nm west of First Narrows. 1.8.3 Traffic Separation Scheme A traffic separation scheme is a routing measure that provides for the separation of opposing streams of traffic, through the establishment of traffic lanes. The scheme in the Strait of Georgia begins north of Boundary Pass and leads north along the east side of the strait into Burrard Inlet. The scheme is recommended for use by all ships, particularly those 20 m or more in overall length. At the time of the collision, the tug and barge had left the outbound traffic lane before its natural terminus and entered the traffic separation zone on a southwesterly heading toward buoy QA. The pleasure craft was in the process of crossing the same traffic separation zone in a southeasterly direction (see Appendix A). 1.8.4 MCTS Centres The CCG provides communications and traffic services for the marine community through MCTS.[3] One of the primary functions of MCTS is to monitor the movement of vessels 20 m or more in length in coastal waters. At the time of the collision, there were two MCTS centres using radar to monitor the movement of marine traffic in Vancouver's outer harbour. MCTS communication with vessels was maintained by means of the assigned VHF reporting frequency, Channel 12. In addition, vessels were required to monitor the international distress and calling frequency, VHF Channel 16. Having an overall length of less than 20 m, the Sunboy did not participate in the Vancouver MCTS system of August 7, nor was she required to have done so. The Jose Narvaez was required to participate in the system, and did. Three times daily, MCTS broadcasts to mariners safety significant information it has received from interested parties. These broadcasts are known as Notices to Shipping, and on August 7 they were made routinely at 0810, 1410 and 2210. It is standard practice to abbreviate the text of a Notice to Shipping after it has been broadcast for 48 hours. As this was the third night of fireworks, an abbreviated version of the following text was broadcast: A fireworks display will take place in English Bay from 2215 until 2245 PDT Saturday Aug 07 1999. Heavy congestion is expected at First Narrows and in False Creek as spectators return from the display. Mariners are advised to exercise caution and where possible remain clear of these areas during times of heavy congestion. All MCTS radar surveillance and radio communications equipment was reported to have been operating normally at the time of the accident. At 2145 Vancouver MCTS received an initial report of the collision from the Jose Narvaez on VHF Channel 12, the MCTS working channel. This report was in non-standard format, in that the prefix of Mayday was not used. The traffic-regulating officer then advised the MCTS safety officer, who initiated a three-second, continuous alarm signal and, at 2147, transmitted a Mayday call on VHF Channel 16. The broadcast advised of the possibility that people might be in the water and requested mariners to proceed to the area to assist. Six minutes later a MCTS safety officer informed the Rescue Co-ordination Centre (RCC) in Victoria of the occurrence. 1.9 Navigation Sunboy The Sunboy was fitted with an interior control station and a command bridge. The navigation equipment at the interior control station included a magnetic compass, a marine radar, a digital depth sounder, a global positioning system device, a VHF transceiver and an electric horn. The command bridge was equipped with a magnetic compass, a VHF transceiver and an electric horn. The compass was the only appliance in use at the time of the occurrence; VHF safety communication channels were not being monitored. The navigation lights aboard the pleasure craft conformed to the number and location of those prescribed by the International Regulations for Preventing Collisions at Sea, 1972 (COLREGS). The switch controlling the activation of the navigational lights was found in the on position at the time the Sunboy was salvaged. The lights were lit at the time of the occurrence. No radar reflector was observed at the time of salvage and its presence or absence at the time of the occurrence could not be determined. While piloting his vessel between Seattle and Vancouver, the operator relied upon a type of publication known as a coastal cruising atlas, in which the editor typically prints a statement to the effect that the charts contained in the atlas are not intended for use in navigation. The operator carried no Canadian or United States hydrographic service charts aboard the vessel. On the evening of the occurrence, one of the guests brought a nautical chart aboard. The operator did not use this chart, and it was not found at the time of salvage. The operator was navigating with reference to a congregation of lights he saw ahead of him in the distance. He understood them to be those of other pleasure craft gathered in English Bay awaiting the beginning of the fireworks. Jose Narvaez The navigation equipment in the wheelhouse of the Jose Narvaez included two marine radars, a magnetic compass, an auto pilot, two VHF transceivers, a Loran-C receiver and a ship's whistle. At the time of the collision, the tug was on automatic pilot, with all of these aids operational except for one radar unit, which was turned off. The Jose Narvaez was displaying the navigation lights for a vessel of her size and type. They comprised three masthead lights, each with a minimum visibility range of five miles. She displayed sidelights, stern light and a towing light, each of which had a minimum visibility range of two miles. The master of the tug was navigating with reference to Canadian Hydrographic Service Chart 3481. Texada B.C. Originally, the barge had been fitted with permanent port and starboard sidelights and a stern light. On August 5, during a nighttime passage from Seattle to Vancouver, the master noticed that the barge's starboard sidelight was flickering. On August7 the barge was prepared for the passage to the Fraser River. The deckhand turned on the switches for navigation lights and checked that the photo cells were operating. He then positioned a (temporary) Scotty lantern that had been improvised and used as a portable starboard sidelight. The lantern was secured with twine to the appropriate side screen of the barge. At the time of departure and when off buoy QB, the master observed the green sidelight of the barge approximately 300 m astern of the tug. 1.9.1 Portable Navigation Lights Photo 5 The lantern that had been aboard the Texada B.C. The substitute light in use aboard the Texada B.C. on the night of August 7 is commonly referred to as a Scotty lantern. It was a 6-volt lantern battery atop which was secured a light assembly with a green lens cap over a clear light bulb. The height of the combined battery and light assembly was approximately 25 cm. Attached to the battery was a wire carrying-handle rising approximately 25 cm above the battery. Tied to the top of the handle of the lantern was a coiled length of twine. The lantern weighed approximately 2.5 kg. Its type is catalogued in the manufacturer's sales material as a barge, boom or portable anchor light designed to be used with a clear lens. It is identified in its packaging as a Barge and Boom Lantern. (The manufacturer indicated that, with a clear lens, the visibility range is approximately 1 nm.) However, the design permits the clear lenses to be replaced with coloured lenses. The TSB had the lantern tested in an independent laboratory five weeks after the collision, in the presence of representatives of both the owner and the TSB. With a green (starboard) lens, the lantern was found to have a maximum visibility range of less than four cables (0.4 nm). International regulations required the sidelight to have a minimum visibility range of 3 nm. The owners of the tug and barge maintained an inventory of these lanterns and occasionally used them on barges as temporary sidelights. This investigation revealed the widespread use of portable kerosene- and battery-operated navigation lights in the West Coast towing industry, particularly on barges and log booms. The visibility range of these lights__most frequently used as navigation lights__is substantially below that required for safety as specified in the COLREGS, which in this instance was 3 miles. These navigation lights have not been tested in accordance with the Transport Canada publication entitled Standards for Navigation Lights, Shapes, Sound Signal Appliances and Radar Reflectors 1991 - TP1861. Navigation lights that meet regulatory requirements are sold with proof of compliance documentation, be it in the form of a document or a label securely affixed to the light. 1.9.2 Previous Safety Communication Regarding Navigation Lights Ship Safety Bulletin (SSB) 13/88, Annex, entitled Recommendations for the Safety of Towed Ships and Other Floating Objects states, in part: 2.1 Tows should exhibit the navigation lights . . . required by the International Regulations for Preventing Collisions at Sea, 1972, as amended. Due consideration should be given to the reliability of the lights . . . and their ability to function for the duration of the voyage. It is most desirable that a duplicate system of lights be provided. Over the past 10 years the TSB has issued safety communications concerning the substandard display of navigation lights, especially aboard working barges. Of specific concern have been lights that were incorrectly configured, had insufficient range, or were not functioning. Any of these deficiencies can seriously compromise the ability of mariners to see another vessel and take timely collision-avoidance action. The following is a summary of these communications: Marine Safety Information Letter 04/91, issued in January 1991, stated that a barge carried no lights after sunset. A 4.8m (16 ft.) pleasure boat collided with the bow of the barge CPR No. 1 pushed by two tugboats Brymay and Telkwa Queen (TSB Report M90W1039). Marine Safety Advisory (MSA) 03/94, issued in May 1994, suggested that the CCG, then part of TC, examine towing industry practices on the West Coast to confirm the adequacy of navigation lights and their display. This MSA was issued during the investigation of the collision involving fatalities between the tug-barge unit Arctic Taglu/Link 100 and the fishing vessel Bona Vista (TSB Report M93W1050). With the investigation report, the TSB issued Recommendation M95-13 in November 1995, proposing that TC ensure that the navigation light requirements for tug-and-barge operations facilitate vessel detection and collision avoidance under all operating conditions, regardless of the tug/barge configuration. MSA 01/99, issued in January 1999, reiterated that TC should ensure that the navigation light requirements for tug-and-barge operations facilitate vessel detection and collision avoidance under all operating conditions, regardless of the tug-barge configuration. Another collision had occurred involving the barge known as Barnston Island No. 3, towed alongside by tug Centurion VI, and the tug Harken No. 5 (TSB Report M98W0239). In response to Recommendation M95-13 and other associated correspondence, TC issued SSB 3/96, which warns the marine community of the dangers associated with the use of navigation lights that do not comply with the COLREGS, be it with respect to the proper carriage, display or technical details. It also advises builders, owners and operators who are unclear as to the requirements for navigation lights on their vessels to contact a TCMS office. TC also advised that initial consultation with the industry had taken place in May 1996, regarding the navigation light arrangements on the type of tug/barge combination, and the industry Working Group is still active in this regard. 1.10 Owners' Directives Regarding Marine Operations 1.10.1 Planned Maintenance Sunboy Following the occurrence, the TSB determined that the main engines of the Sunboy were nearly new at the time of the accident and no major maintenance was planned or required. The engines had operated for a total of 300 hours. Jose Narvaez and Texada B.C. Prior to this occurrence, the Jose Narvaez completed her most recent TCMS inspection in May 1997, and was scheduled for her next inspection in May 2001. When equipment aboard either the tug or barge is found to be defective, it is the owners' standard procedure that a responsible crew member report the fact to the shore engineer by VHF radiotelephone. Subsequently, a written description of the defective equipment is submitted to the same shore engineer. The description is made using a Maintenance Order Requisition. Once the equipment has been repaired or replaced, the Maintenance Order Requisition is not retained. In this instance, the non-functioning starboard sidelight on the Texada B.C. and the non-operational intercom system on the Jose Narvaez were not reported to the shore engineer until after the accident. 1.10.2 Tug Company's Instructions to Master The company's principles and philosophy include a long-term approach to operating performance, quality assurance (business, products and safety of all employees), the development of employee skills, and sound environmental practices. In keeping with their human resource and operating philosophy, the Master Standing Orders outline the company's policies for shipboard and shore-based personnel. The instructions include some reference to the responsibilities of the master and the crew and their duties to both navigational and maintenance requirements. Among other requirements, the Master Standing Orders stipulate that: the master is responsible for the safety of the vessel, including crew training; the master should ensure that the efficiency of all equipment is maintained; navigation personnel should comply with COLREGS, (including that navigation lights are properly displayed and working satisfactorily, and that a proper look-out is maintained); extra precautions should be taken in high density traffic which may include reduction in speed and/or posting of extra lookouts; and log books should include entries with respect to high traffic density and deficiency of equipment. In this instance there was no entry in the log book to indicate that the intercom was not functioning satisfactorily or that the barge's permanent starboard sidelight was inoperative. Also, while operating in the vicinity of a relatively high level of pleasure craft traffic, the master did not post a lookout. Upon deciding that a lookout was required, and without the benefit of the intercom, the master left the bridge unattended and proceeded below decks to summon the deckhand. 1.11 Collision Avoidance Sunboy The vessel's radar was next to the main deck interior control station and any navigational information displayed on it was unavailable to the operator seated at the control station on the command bridge. The operator did not recognize the tug JoseNarvaez despite its being lit with the appropriate navigation lights. The operator recalls seeing a dark object to port, which he identified as an island but which was in fact the hull of the barge Texada B.C., against the dark background of Stanley Park, seen at close range seconds before the collision. Neither the operator of the Sunboy nor others who observed the accident saw a green sidelight aboard the barge. Jose Narvaez When the tug was approximately one mile west of First Narrows, the towline was extended to 274 m and the deckhand went below decks, having been given permission to do so. Being alone in the wheelhouse, the master assumed the dual responsibilities of navigator and lookout. While aware that there were many pleasure craft in the area, the master did not identify the Sunboy or effectively monitor other vessels in the area. The tug's heading was maintained by automatic pilot. After passing buoy QB and established on a heading of 245T, the master proceeded below decks in search of the on-watch deckhand. Once he had arrived back in the wheelhouse, seconds prior to the collision, he remained unaware of the presence of the Sunboy. 1.12 Emergency Planning and Response 1.12.1 Management of Traffic during Special Events Between 2,800 and 3,000 deep sea vessels arrive in the Port of Vancouver each year. The Harbour Master (HM) directs the operations of the Vancouver Port Authority and uses a Standard Operating Procedure for judging the acceptability of all special event applications involving Vancouver Harbour. Approximately three to four applications are processed weekly. The approval process may require only a cursory examination of the event's requirements and potential impact on port operations, or it may demand in-depth study requiring consultation with shipping agents, police, fire and ambulance services, the CCG, MCTS, and others. Fireworks displays have been held annually in English Bay since 1990. There are two displays each week for two consecutive weeks, beginning in the last week of July or the first week of August. Each event begins at 2215 and lasts 30 minutes. Each year, months in advance of the first display, members of the CCG, Emergency Health Services, MCTS, Vancouver Police Department, Vancouver Port Authority, and the event's corporate sponsors meet on several occasions to coordinate the best use of available resources. Strategies are developed for restricting pleasure craft from entering an area dangerously close to the fireworks barge, communication protocols are established between designated patrol vessels, and plans are made for inspecting life-saving equipment aboard pleasure craft bound for English Bay on event evenings. On August 7 some 10 vessels of various types were engaged in the task of patrolling English Bay, where the majority of pleasure craft had gathered. The Vancouver Port Authority provides the services of one or more vessels to assist commercial traffic through First Narrows. This policy is in effect year round and is not restricted to special events. However, the offer is conditional upon the availability of vessels to perform the service. At the time of the accident, the Vancouver Port Authority considered its policy to be known generally by commercial shipping using Vancouver Harbour. During the four Symphony of Fire events of 1999, the Vancouver Port Authority coordinated the patrol vessels at the event in Vancouver harbour, through collaboration with the CCG and CCG-auxiliary personnel, the Vancouver police and fire departments, Vancouver Life Guards and Jericho Rescue. To ensure the unimpeded transit of commercial vessels and the safety of all traffic in the area, including that of pleasure craft, the HM carefully examines events with the potential to affect commercial ship movements. In anticipation of high levels of pleasure craft traffic in the harbour on the nights of the Symphony of Fire, the Harbour Master had initiated a Notice to Shipping. The Port of Vancouver Harbour Operations Manual states that escorts will be provided as follows: For tankers, the HM's launch will be available to clear traffic and provide services through First and Second Narrows. During high-traffic times, the HM's launch will be available to provide escorts for cruise ships through First Narrows. In extraordinary circumstances the HM's launch will be available to provide escorts through Vancouver Harbour for other vessels, if requested. Further requirements for tankers include tugs escorts through the harbour and tugs to stand by tankers at anchor in English Bay. Tug assistance is at the cost of the ship's owners. The collision took place approximately 3.5 miles west of First Narrows and some 3.5 miles northwest of the fireworks barge, in the area of the traffic lanes. It is an extremely popular area with the pleasure boating community, with marinas and yacht clubs located on both the north and south shores of Burrard Inlet. Escorts are provided to commercial vessels in this area in unusual circumstances or upon request. On the night of the accident, MCTS evaluated commercial vessel participation in the traffic scheme as being light to moderate. However, as a result of the fireworks display, an unusually large number of recreational water craft were observed by radar to be gathering in Burrard Inlet in the vicinity of the fireworks barge before the start of the fireworks display. The CCG estimated that between 1,000 and 1,200 vessels attended the August 7 event, including a cruise ship, small commercial passenger vessels, numerous recreational power and sail boats, as well as canoes and kayaks. On the day of the occurrence, the Vancouver Port Authority vessel Klawichan was available as an escort vessel during the early evening hours, but by 2030 it was fully engaged in patrolling the area next to the fireworks barge. Hence, when the 236.45-m-long, 36,028 gross tonnage container vessel PO Nedlloyd Seattle requested an escort (prior to the occurrence), the vessel was informed by MCTS that none was available. The vessel transited the area without an escort. Four days later, on August 11, during another fireworks event, the 199-m-long general cargo vessel Star Hosanger (33,364gross tonnage) was observed inbound approaching First Narrows at about the same time as many pleasure craft were transiting the Narrows. On that occasion, two vessels provided an escort, one on either side of the commercial vessel. Sirens were sounded, searchlights were trained on the vessel's hull, and loudhailers were used to draw the attention of pleasure craft__to warn them to keep clear of the commercial vessel. 1.12.2 Search and Rescue Search and rescue (SAR) service is initiated by RCC Victoria, which in turn notifies EHS, in Vancouver. EHS coordinates and provides the first response, which is typically ambulance and first aid assistance. West Vancouver Fire Hall No. 3 is within five minutes' driving time of the Fisheries dock (where the victims were brought ashore). The firefighters on duty that night were qualified to provide skilled emergency assistance, and they held a key to unlock the gate leading from a public roadway to the Fisheries dock. However, EHS did not immediately inform personnel at Fire Hall No. 3, and their assistance was not sought until 25 minutes after the first ambulance had arrived at the landing site. 2.9 MCTS__Limitations Imposed by Traffic Many pleasure craft were known to be operating in the general area, including open boats with no provision to affix a radar reflector, which makes their detection on the radar difficult. Further, a large number of these craft are not required to participate in the Vessel Traffic Services (VTS) system. In the given situation, vessels would pass each other at close range, which would make merging of targets a common event. Given the bearing and range discrimination of radar sets and given the volume of non-commercial vessels operating in the area, MCTS monitoring and communication of information respecting merging of targets is not considered practical.